Otolaryngology Coding Alert

HCFA has revised section 15047 of the Medicare Carriers Manual (MCM) to ensure that local Medicare carriers allow the use of V72.81-V72.84 to provide medical necessity for preoperative clearance exams.

According to Medicare transmittal R1707-B3, dated May 31, "Carriers should delete any processing edits that deny claims or identify for manual review ICD codes V72.81 through V72.84." However, "claims containing these codes are subject to medical necessity determinations as described in MCM section 15047H."

According to the new language in section 15047C, Medicare will pay for all medically necessary preoperative clearances, such as those that involve "evaluating a patient's risk of perioperative complications and to optimize perioperative care."

This means, for example, that when a surgeon sends a patient to a primary care physician, cardiologist or neurologist for preoperative clearance, the appropriate V code -- rather than the condition that prompted the concern or the condition that warrants surgery -- may be used to justify the examination.

According to the revised language in section 15047G, "All claims for preoperative medical examination and preoperative diagnostic tests (i.e., preoperative medical evaluations) must be accompanied by the appropriate ICD-9 code for preoperative examination (e.g., V72.81-V72.84). Additionally, the appropriate ICD-9 code for the condition(s) that prompted surgery must also be documented on the claim. Other diagnoses and conditions affecting the patient [presumably, the condition that prompted the surgeon to send the patient to the cardiologist or neurologist for the preoperative clearance] should also be documented on the claim, if appropriate."

The transmittal specifies, however, "The ICD-9 code that appears in the line item of a preoperative examination or diagnostic test must be the code for the appropriate preoperative examination (e.g., V72.81-V72.84)."

Medical necessity for such preoperative clearances remains at the discretion of the local Medicare carrier, HCFA says.